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SAN J QA Q U I N Environmental Health Department <br /> _ N ; <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPUCANT <br /> Business Name .sem Lic. Plate# <br /> Owner/Operator Name 1 <br /> Busine s Mailing Address { 1� <br /> City State zip q< Bus. Ph.M 25 Alt. Ph. <br /> i; hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe tie ra <br /> SignatureG"� Date SO <br /> 2. To be-dompleted'by COMMISSARY OWNER/OPERATOR' <br /> Commissary Name r <br /> a� ni-CA <br /> Addres Bus. Phone <br /> City 5 Zip S10Owner/Operator (� <br /> Check all appropriate services provided <br /> Wastewater disposal 0-"3-compartment sink fectrical hook-ups <br /> Solid waste disposal G—Food preparation valet and handwashing <br /> Cold water for cleaning Store_refrigerated food P41otable water <br /> tore dry food/supplies Overnight parking vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary QWner sh notify the EHD immdi tely. <br /> Signature Date <br /> I Ta be r ptetect'( :t e.EWHEALTH 06scl rot oPde <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org;ehd <br />